Socioeconomic patterns in health behaviours after disease onset
Authors: Mika Kivimäki, Michael G Marmot
Journal: The Lancet Public Health (2022)

Socioeconomic circumstances shape health-related behaviours beginning in childhood, contributing to inequalities in health later in life.1Commission on Social Determinants of HealthClosing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization, Geneva2008Google Scholar In the 1958 British birth cohort study,2Power C Matthews S Manor O Inequalities in self-rated health: explanations from different stages of life.Lancet. 1998; 351: 1009-1014Summary Full Text Full Text PDF PubMed Scopus (226) Google Scholar behavioural and material factors in early life explained about a third of the excess risk of poor health among adults with low socioeconomic status (SES). In the Young Finns Study,3Kivimaki M Vahtera J Tabák AG et al.Neighbourhood socioeconomic disadvantage, risk factors, and diabetes: a cohort study from childhood to middle age.Lancet Public Health. 2018; 3: e365-e373Summary Full Text Full Text PDF PubMed Scopus (81) Google Scholar early childhood SES established a temporal sequence that distinguished low and high SES groups across the life course: lower fruit and vegetable intake at age 6 years in low SES groups; lower physical activity and higher prevalence of smoking in adolescence; adverse biological changes, evident by early adulthood (eg, reduced insulin sensitivity and higher fasting glucose); and greater risk of chronic conditions, such as obesity, fatty liver disease, and type 2 diabetes by age 48 years. A systematic review4Petrovic D de Mestral C Bochud M et al.The contribution of health behaviors to socioeconomic inequalities in health: a systematic review.Prev Med. 2018; 113: 15-31Crossref PubMed Scopus (182) Google Scholar of over 100 papers showed the significant contribution of health behaviours to the association between SES and health outcomes into old age, although results varied by geographical region and health outcome. In The Lancet Public Health, Danyang Wang and colleagues5Wang D Dai X Mishra SR et al.Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study.Lancet Public Health. 2022; 7: e670-e682Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar present a study that expands this field of research. By asking what happens to socially-patterned health behaviours after onset of disease, the investigators shift the focus from health behaviours as risk and protective factors to factors that modify the progression of disease—ie, prognostic factors (figure). Increased research attention on those with non-communicable diseases is timely. Because of population ageing, this group of people is growing fast world-wide. Wang and colleagues pooled data from six prospective cohort studies in the UK, Europe, North and Central America, and Asia, including 8107 individuals diagnosed with diabetes, cardiovascular disease, chronic lung disease, or cancer after baseline.5Wang D Dai X Mishra SR et al.Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study.Lancet Public Health. 2022; 7: e670-e682Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar Most participants (7248 [89·4%] individuals) were from three datasets from high-income countries: the Survey of Health, Ageing and Retirement in Europe; the English Longitudinal Study of Ageing; and the US Health and Retirement Study. Participants were surveyed every 2 years with assessments both before and after disease diagnosis, providing a robust longitudinal study design. The authors observed both favourable and unfavourable changes in health behaviours after disease onset. In the total study population, the proportion of people who smoked decreased from 18% to 14% after diagnosis, but prevalence of physical inactivity increased from 18% to 24%. These changes were less favourable in low-SES than in high-SES groups. For example, among those who were physically active before disease development, a greater proportion of individuals in the lowest SES stratum became inactive compared with in the highest SES stratum. Among those who were physically inactive and smoking before diagnosis, low SES participants were more likely to continue these unhealthy behaviours compared with high SES participants. As a result, 432 (41%) of 1067 people in the lowest SES stratum but only 70 (10%) of 685 in the highest SES stratum were physically inactive after disease diagnosis. The key message that should be taken from this study is that social patterning of health behaviours increases further after disease diagnosis. This conclusion is consistent with results from the Whitehall II study,6Singh-Manoux A Fayosse A Sabia S et al.Clinical, socioeconomic, and behavioural factors at age 50 years and risk of cardiometabolic multimorbidity and mortality: a cohort study.PLoS Med. 2018; 15e1002571 Crossref PubMed Scopus (80) Google Scholar which showed that socioeconomic disadvantage not only contributes to the transition from a disease-free stage to incident cardiometabolic disease, but also predicts progression to cardiometabolic multimorbidity. The findings by Wang and colleagues5Wang D Dai X Mishra SR et al.Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study.Lancet Public Health. 2022; 7: e670-e682Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar are also in agreement with the evidence on social inequalities in other outcomes affected by health behaviours and observed in individuals with pre-existing diseases, such as frailty7Brunner EJ Shipley MJ Ahmadi-Abhari S et al.Midlife contributors to socioeconomic differences in frailty during later life: a prospective cohort study.Lancet Public Health. 2018; 3: e313-e322Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar and dementia;8Satizabal CL Beiser AS Chouraki V Chêne G Dufouil C Seshadri S Incidence of dementia over three decades in the Framingham Heart Study.N Engl J Med. 2016; 374: 523-532Crossref PubMed Scopus (659) Google Scholar shorter life expectancy;9Mackenbach JP Valverde JR Bopp M et al.Determinants of inequalities in life expectancy: an international comparative study of eight risk factors.Lancet Public Health. 2019; 4: e529-e537Summary Full Text Full Text PDF PubMed Scopus (83) Google Scholar and death.10Stringhini S Carmeli C Jokela M et al.Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women.Lancet. 2017; 389: 1229-1237Summary Full Text Full Text PDF PubMed Scopus (669) Google Scholar Wang and colleagues5Wang D Dai X Mishra SR et al.Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study.Lancet Public Health. 2022; 7: e670-e682Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar did not have data on all relevant health behaviours, leaving several questions remaining. For example, data on diet, alcohol consumption, weight management, and adherence to treatments were missing. The authors focus on continuing or initiating unhealthy behaviours, but not on giving up unhealthy behaviours after diagnosis, presents a partial picture. Because of a small sample size, Wang and colleagues merged people with different chronic conditions into a single study population. Larger-scale disease-specific analyses would enable better control for disease profiles patterned by SES. Further research is also needed to link behavioural changes after diagnosis to subsequent progression of the disease, which would provide a more comprehensive analysis of the interplay between SES, health behaviours, and disease processes (figure). Despite these limitations, the evidence by Wang and colleagues informs secondary prevention of common chronic conditions. By increasing understanding of social differences in health behaviours among people with pre-existing disease, the study aids in planning interventions that seek to allocate efforts proportionately across the socioeconomic gradient.1Commission on Social Determinants of HealthClosing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization, Geneva2008Google Scholar The findings suggest that to improve health equity, extra support for lifestyle modification is needed for socially disadvantaged individuals living with chronic disease. We declare no competing interests. Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort studyLow SES was associated with continuing or initiating physical inactivity and continuing smoking after NCD diagnosis. Reducing socioeconomic inequality in health behaviour changes should be prioritised and integrated into NCD-prevention programmes. Full-Text PDF Open Access